HomeMy Public PortalAbout4847 ARDSLEY DR_Miscellaneous__ (2) • WORKERS'COMPENSATION DECLARATION 76M444 p p I SC E L LA N E®u sAPPLICATION
I I�J�
CE 875 (11-84)
I hereby affirm that I have a certificate-ofconsent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,.Lab.C.). .
Policy No. CompanyFOR APP LI CANT TO FILL IN BUILDING R ' �
ADDESS
Certified co is hereby furnished. BUILDING y�/ / )
❑ copy y ADDRESS / �,��(� ��� LOCALITY
Certified copy is filed with the county building inspection LOCALITY�Y��/�Jjl/�/ // O NEAREST
department. / /i/ G ( ` CROSS ST.
Date Applicant NEAREST _ i �� DISTRICT NOS GR� P CONST / PROCESSED BY
CROSS ST. /
l /J)
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL I
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP ,f '/� / HIGHWAY
rvo. `J fJ/lQ (CIRCLE) STATE MAJOR SEC04 D LOCAL
NO. OF BLDGS.
(This section need not be completed if the work"involved I TRACT NOW ON LOT USE ZONE SPE IAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) usE of
I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. o
permit is issued, I shall not employ any person in any manner OWNER 'E`Q AJ Q V Nf ='
so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY,GROUP', o
ADDRESS S �_� ''• _
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of: CITY �� ryo���� L D S y OCCUPANT LOAD
Exemption, you should become subject .to the Workers' APPLICATION FOR EXIT HARDWARE:
Compensation provisions of the Labor Code, you must forth
with comply with such provisions oI this permit Shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. �j
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION IXI Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code; and my license is in full force andT (J 1 ��¢ t SS�/L✓ �OO FSARKING
effect. REQ'D PROVIDED
SPACES
License Number Lic. Class
LIMITED TIME USE
Contractor Date DATE DAT E
❑ I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a .registered professional engineer SIZE OFNO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus
EXISTING BLDG. STORIES SI ATURE
iness and Professions Code). FINAL APPROVAL
Lic.or Reg.No. Date
PRESENT USE OF BUILDING (( {�
HOME OWNER-BUILDER DECLARATION NO.OF,EXISTING BUILDINGS # a 0 0 0•3 0
ON LOT AND USE '
I hereby affirm that I am exempt from the Contractor's I o o 8050
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO.PARKING o 0 o 8 0.5 0 5
�I, as owner of the property, will do the work and the SPACES PROVIDED L ^
structure is not intended or offered for sale (Sectionn ��L Till ��� — ��SS/N Gbit '01 1-4-48 8,
7044,Business and Professions Code). -
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING
I hereby affirm that there is a construction lending agency r
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.).
Lender's Name
PROPOSED MAX. OCC.
Lender's Address
'
I certify that I have read this application and state that the PERMIT FEE
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE U
upon the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE.
Signature of Permittee -,Date/ `J